The World Book of Family Medicine – European Edition 2015
Theo Schofield, OBE FRCP FRCGP
[email protected]
25 – The New Consultation: The Doctor in the Electronic Age
Theo Schofield OBE FRCP FRCGP,
retired Lecturer and Fellow of
ETHOX, Department of Primary
Care University of Oxford.
Co-author
Peter Havelock, retired Associate
Advisor in General Practice,
Oxford Deanery.
The New Consultation: developing doctor-patient communication, (Pendleton et al
2003), and it’s predecessor The Consultation: an approach to learning and teaching
(Pendleton et al 1984) both described:

the current literature on Doctor Patient communication

the ideas, concerns and expectations that patients bring to their consultation

the opportunity that each consultation has to develop the patient’s
understanding

the potential to develop the relationship between the doctor and patient over
time.
Based on this “Cycle of Care” we were able to describe Tasks to be achieved in
the consultation, which in summary are:
Understanding the patient’s problem
Understanding the patient
Sharing understanding
Sharing decisions
Sharing responsibility, and
Developing a relationship that helps to achieve the other tasks.
Are these still relevant in “The Electronic Age” characterized by the emphasis on
Evidence Based Medicine and Shared Decision Making, by new technologies, and by
developments in health care systems?
Evidence based medicine aims to improve the quality of the evidence on which
clinical decisions can be based. However most evidence is derived from populations,
while the clinician is dealing with an individual patient, and that the approach can
generate a “right” answer, with which the clinician, and in turn the patient, is
encouraged to comply.
Shared decision making, or Evidence Based Patient Choice (Elwyn et al 1999),
responds to these criticisms by an approach where clinicians and patients make
decisions together using the best possible evidence. This involves presenting the
evidence about diagnosis, options for treatment and it’s benefits and harms and
uncertainties, in ways that are fully comprehensible to patients, and encourages and
enables patients to make choices about their own care.
There is evidence that shared decision making can produce better informed patients
who are less passive, who adhere better to treatment, and who sometimes make
more conservative decisions about treatment. There is strong professional and
institutional support for the implementation of shared decision making. (The Salzburg
Declaration 2010).
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The World Book of Family Medicine – European Edition 2015
Another major technological change is the almost universal presence of the Computer in the Consulting Room. This
has transformed record keeping, particularly in primary care. They can provide structured records and templates for
the management of chronic conditions, for results and for screening and prevention. The patient’s record can be
shared with other team members, and across sites, and in some settings patients can access their own records, and
become more involved in their own care.
Computerization of the consultation can also bring problems. It can interfere with maintaining eye contact with the
patient, and can influence the doctor’s agenda to be more structured and task orientated in response to the templates
and prompts of the computer. Bensing et al in 2006 found that in two sets of recorded consultations with patients with
hypertension separated by 10 years, the technical quality of care by the doctors improved, while the patients spoke
less, asked fewer questions, and expressed fewer concerns and worries. She speculated that this reflected the shift
towards more evidence based protocol driven care, as well as the influence of the computer in the room.
Computers also allow doctors and patients to access information, guidelines and decision aids either in the
consultation, or for patients to consider afterwards. This can also include examples of patient experiences on sites such
as Healthtalk (Ziebland et al 2013).
The telephone is being used increasingly as a means of communication with patients in many settings. It can improve
access and follow up, it can be convenient for patients, and can be a more efficient use of doctors’ time. On the other
hand a telephone consultation does not involve face to face contact, omits visual cues and physical examination, and
both the doctor and the patient may feel that it was a “second best” and riskier encounter.
Other modes of communication such as Email, Web sites and Social Media are less well established but offer
opportunities for innovation, as does self-recording and monitoring using smart phones. All have the potential to help
patients become better informed and more in control of their own health care. However it is face to face contact that
builds mutual understanding and trust between doctor and patient.
Continuity of Personal Care is valued by many patients, particularly those that are older, have long term medical
conditions or psychological conditions. Supporters of personal continuity argue that personal continuity leads to
increased patient satisfaction, more trust, and better care (Gray DP et al 2013). However, in the United Kingdom the
health care system has recently given greater weight to accessibility, which is also valued by patients. Changes in the
contract with general practitioners, and increased shift working in hospitals, have made the delivery of personal
continuity more difficult.
Per Fugelli in his James Mackenzie Lecture in 2001 defined Trust as the individual’s belief that the sincerity,
benevolence and truthfulness of others can be relied on, and that trust often implies a transfer of power to a person,
or to a system, to act on one’s behalf, in one’s best interest. He described personal trust as the trust you have in an
individual, such as your doctor, and social trust as trust in societal institutions such as the government or health care
institution. He went on to describe the influence that trust, or the lack of it, has on the process of the consultation.
Take Home Messages

Understanding the patient, their problems and their perspective remains an essential task in an effective
consultation.

Shared Decision Making can enable patients and improve their care.

New technologies offer new opportunities for communication, but should not be a substitute for face to face
contact.

It is essential that we maintain the trust of patients in their doctor, the medical profession and the health care
system.
Original Abstract
http://www.woncaeurope.org/content/466-new-consultation-doctor-electronic-age
References
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Pendleton D, Schofield T, Tate P and Havelock P. 2003. The New Consultation. OUP .Oxford.
Pendleton D, Schofield T, Tate P and Havelock P. 1984. The Consultation: an approach to learning and teaching OUP.
Oxford.
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The World Book of Family Medicine – European Edition 2015
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Elwyn G, Edwards A and Kinnersley P. Shared decision making in primary care: the neglected second half of the
consultation. BJGP 1999; 49 :477-482.
The Salzburg statement on shared decision making BMJ 2011;342: d1745.
Ziebland, S Coulter A Calabrese J Locock L (Eds) (2013) Understanding and Using Health Experiences: improving patient
care. OUP. Oxford
Bensing JM et al. Shifts in Doctor-patient communication between 1986 and 2002: a study of videotaped general practice
consultations with hypertension patients. BMC Family Practice 2006; 7: 62
Gray DP, White E and Evans P. The importance of continuity of care. BJGP 201464:446.
Fugelli P. Trust - in general practice. BJGP 2001;51: 575-579.
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